Why Your Best Growth Year Is Your Biggest Audit Risk

In 1998 a law change in New York gave everyone with insurance access to chiropractic. Dr. Matt DiDuro's practice doubled, then tripled, in about ten months.

His notes didn't keep up. Date, whether they paid the copay, a quick listing, done. He was too busy adjusting to think about it.

Four years later, the insurance company asked to see six charts.

That started a six-year audit. By the end, the demand had grown to $150,000, there was a federal review of his Medicare files, and he had to sell the practice he'd built into one of the largest between the two big cities in Central New York.

Matt's been a chiropractor for more than 30 years. These days he spends most of his time training other providers on SoftWave, and he still works in his Atlanta clinic.

How does an insurance audit start?

For Matt, slowly. First six charts. He failed. About every ten months, they asked for six more. His scores kept improving, from 38% to 55% to 66%. Then a special investigations unit showed up and asked for 32.

He says the trigger was a former associate who was getting ready to buy the clinic. According to Matt, a friend told the associate that a practice under audit sells for 50 cents on the dollar.

Then the numbers kept climbing. First the insurer wanted $1,500 back for a week Matt was at a seminar while his associate treated patients. Then $15,000. Then $30,000, then $60,000. Then $150,000, claiming he hadn't collected copays. His compliance attorney told him not to pay the first $1,500, because paying it was admitting he'd done something wrong. The contract said he hadn't.

On the copay claim, Matt's point is you're not a collection agency. You send one or two notices. They billed the list once and collected about $5,000.

He spent six years proving himself innocent, with a healthcare attorney and a business attorney. Years later he went after the former associate through arbitration and won an award covering more than half of what he was after.

What does audit-proof documentation look like?

Matt's version is SOAP: subjective, objective, assessment, plan. Every visit, every time.

He went from minimal notes to formal training in healthcare compliance and documentation. His view is that auditors target chiropractors because our notes are notoriously bad, and they know an audit pays.

Today he records the patient history on his phone, and his EHR prompts him for the right orthopedic tests and builds the note. He also records patient videos into the chart, so he can show range of motion at the start and at the end of a plan.

His other lesson: the agreements matter. If an associate sees something wrong, the right move is to report it to the practice's compliance officer, not to call the insurance company.

How did he rebuild to 140 new patients a month?

By letting patients tell the story.

When COVID shut down his Atlanta neuropathy clinic (his average patient was 71, and they all stayed home), Matt had about five weeks to figure out a new plan. He'd already been using SoftWave for a few years, so he started running Facebook ads built around real patient videos: what someone could do before one visit, and what they could do after.

His previous agency had been running one condition-specific campaign at a time and charging accordingly. The new approach went broad. And it worked fast.

April: 12 new patients. May: 24. June: 50. Then 75, 100, 125, 140. He averaged 140 new patients a month for more than two years, hired four more doctors, and brought nearly his whole team back.

The cost dropped from about $290 to get one neuropathy patient in the seat to $8 to $10 per new patient on Facebook. His entry offer was a 10-visit pack at $1,250. "I just wanna get on first base."

The idea came from his wife. He'd come home with stories about patients, and she'd ask if he filmed it. Eventually he started.

How many new patients do you need?

Matt made $15,000 his first full year in practice. He and his wife had just had their first daughter, and he realized they qualified for public assistance.

So he sat down at a Chinese buffet and did the math. About $1,000 per case. A hundred cases is $100,000. That's roughly eight new patients a month. He wanted more than that, so he worked backward to how many new patients he needed per week, and then to the events and talks that would get them. Every talk he gave brought in four or five.

He was scared to speak in public, so he started small: fifth graders at the elementary school next door. Two of the school staff became patients.

Common questions

Q: What triggers an insurance audit of a chiropractic practice?

A: In Dr. Matt DiDuro's case, he says a former associate triggered it while trying to buy the practice at a discount. More generally, he believes rapid growth and aggressive marketing draw attention, and that chiropractors are frequent targets because documentation across the profession is weak. His audit started at six charts and expanded over six years.

Q: How should chiropractors document visits to survive an audit?

A: Matt DiDuro recommends complete SOAP notes for every visit: subjective, objective, assessment and plan. He now records patient histories into his EHR, gets prompts for the right orthopedic tests, and adds before-and-after video to the patient chart. He learned the hard way that a busy practice with thin notes is exposed.

Q: Should a chiropractor pay an insurance company's repayment demand?

A: Matt DiDuro's compliance attorney told him not to pay an initial $1,500 demand, because paying would amount to admitting he'd done something wrong when his contract allowed what he did. Matt's takeaway is to get a healthcare compliance attorney involved early rather than settling to make it go away.

Q: How do you reverse-engineer new patient goals for a chiropractic practice?

A: Start with what a new patient is worth. Matt DiDuro estimated about $1,000 per case, so 100 new patients meant roughly $100,000 a year, or about eight a month. He then broke that into a weekly target and planned the events and talks needed to hit it. Each talk brought in four or five new patients.

Q: Do patient testimonial videos work as chiropractic ads?

A: For Matt DiDuro, they rebuilt the practice. During COVID he ran Facebook ads built on real before-and-after patient videos and went from 12 new patients in April to 140 a month by October, averaging 140 a month for over two years. He says letting patients tell their own stories has driven his marketing for three decades.